Labor Induction

• Why Induction?
• What is Induction of Labor?
• Types of Labor Inductions: Elective vs Medical 
• Common Reasons for Medical Induction of Labor 
• Common Reasons for Nonmedical Induction of Labor 
• Who should not be induced?
• What are the Risks of a Labor Induction? 
• What Methods are Used for Labor Induction? 
• How will my doctor decide which medicines or methods to use for my induction?
• Labor Augmentation

Why Induction?

As you near the end of your pregnancy, it’s natural to start to wonder what your labor and delivery “story” will look like. Naturally, you would have formed some expectations of this event based upon stories passed on through family, friends, books, and other resources. You may have imagined being awakened by contractions in the middle of the night, shaking your husband awake while breathlessly announcing, “I think it’s time!” Of course, today, many factors influence how your story plays out. The ability to diagnose problems in pregnancy early has fueled an increase in recommendations for the induction of labor. This article is here to provide factual, real-world information, that will help you navigate the end of your pregnancy when an induction of labor becomes a part of your story.

Often, labor induction is recommended when there is concern that your placenta may be nearing the end of its natural “life-span”. The placenta is a vital organ that plays a critical role in your pregnancy. Much like your heart, lungs, kidneys, and liver helps your body function. The placenta helps the wonderful machinery that is your pregnancy function. It is not possible to overstate the importance of your placenta working well and staying healthy. However, unlike your actual heart, lungs, kidneys, and liver, the placenta isn’t designed to work correctly for years. As your pregnancy progresses, your placenta’s function decreases. At one to two weeks past your due date, the placental function will sharply decrease. Indeed, there is an increased risk of stillbirths in pregnancies at this stage. For this reason, your doctor will recommend induction of labor if you haven’t gone into labor on your own by 41 weeks gestation, which is one week past your due date. 

Inductions are also recommended for medical conditions that will progressively worsen and pose a serious risk to your pregnancy. At times, your obstetrician will even make a labor induction recommendation before your baby has achieved full maturity. These decisions are not taken lightly. They are made when there is a significant risk of long term complications or even death in mother or baby. For this reason, the difficult decision may be made to deliver your baby, knowing this will result in the baby being admitted to the neonatal intensive care unit (NICU).

Some other reasons moms might choose induction of labor are more personal. These include the need to control the timing of delivery, relief from the discomfort of late pregnancy or relief from anxiety. These are called “social” reasons for induction of labor. The induction is referred to as an “elective induction of labor.” Social inductions are still important and valid reasons to consider delivery. There is just one criterion for social inductions- you must be at least 39 weeks pregnant. Although your doctor is sympathetic to your social concerns, these inductions are never recommended before 39 weeks. The risk to your baby is too great to justify a delivery for social reasons before 39 weeks. A 39 weeks pregnancy is one that is at one week before your due date. You must be 39 weeks or greater to be considered for a social (elective) induction of labor. 

What is Induction of Labor?

Induction of labor is a term used to describe the medical process of taking a non-laboring pregnant woman and putting her into labor. The process uses medicines or devices to initiate labor. 

Labor induction is rarely necessary for most women, occurring in only about 20-25% of pregnancies in the US. Given enough time, your pregnant body can initiate this process all on its own. However, there are times when this process is not self-initiated, or a decision is made to bring about labor earlier than your body has planned. 

Types of Labor Inductions: Elective vs Medical

There are only two reasons for labor induction- a medical reason or a nonmedical reason. Inductions occurring for nonmedical reasons are called elective inductions. A medical induction describes the process of bringing on labor for the purpose of sparing you or your baby the medical risks of continuing your pregnancy. 

An elective induction describes a process of bringing on labor for the purpose of achieving a nonmedical benefit. The top three reasons for elective labor inductions are convenience, convenience, and convenience. Your delivery is timed to achieve control and convenience. You may elect to time your baby’s delivery, so your favorite doctor will deliver you in your group’s practice. You may live in a remote area and worry that you may not make it to the hospital in time for your delivery. You may want your delivery to coincide with your maternity leave or time to your support person’s availability. There are plenty of reasons for manipulating the timing of your baby’s delivery. As long as you have made it to at least one week before your due date, that is fine. Numerous medical organizations agree that elective induction of labor should only take place in pregnancies that are at least one week (39 weeks or greater) from their due date, never sooner. Deliberately delivering your baby sooner than 39 weeks, for a nonmedical reason, carries an unacceptably high risk of your baby being admitted to the neonatal intensive care unit (NICU) in the hospital. The NICU is the intensive care unit for babies. All elective inductions must wait until your pregnancy has completed at least 39 weeks. 

Medical inductions occur in pregnancies that have developed a complication. In that case, your obstetrician will make a recommendation regarding the timing of your delivery. Of course, you will take part in this decision, and the recommendation will be based on the severity of your illness. Your obstetrician will consider the risks of continuing the pregnancy versus early delivery. If your medical complication is stable, your team may choose to monitor you closely while allowing your pregnancy to continue. Pregnancies that have developed complications are rarely allowed to go past their due date. 

Common Reasons for Medical Induction of Labor

• Post Dates Pregnancies- pregnancies that have passed their due date 
• Hypertensive disease of pregnancy (Chronic Hypertension, pre-eclampsia, gestational hypertension) 
• Abnormal growth of your baby (IUGR) 
• Diabetes 
• Breaking your water in early pregnancy (PPROM) 
• Chorioamnionitis (infection in the uterus) 
• History of previous stillbirth 
• HIV 
• Multiple Gestation- Twins or more 
• Maternal Heart Disease 
• Babies needing special care at delivery 
• Oligohydramnios- low amniotic fluid  

Abnormal Placentation- placenta developing in the weaker portion of the uterus, which can cause internal or external bleeding.  

Common Reasons for Nonmedical Induction of Labor 

• Scheduling Convenience 
  • to accommodate you or a family member’s schedule 
  • military families where a spouse may be facing deployment 

• Control of Delivery Timing 
  • if you live in a remote location 
  • desire to be delivered by a particular doctor in the group 

• Ease Anxiety  
• Relief from Pain/Discomfort of Pregnancy 

Who Should Not be Induced?

• Breech Pregnancies 
• Placenta Previa- placenta lies directly over the cervix 
• Previous Uterine Surgery (depending on type of surgery) 
• Active Herpes Infection 

What are the Risks of a Labor Induction?

Labor induction can be a lengthy process. Inductions have more vaginal exams and longer hospital stay. For this reason, two outcomes increase with labor inductions- infections and cesarean sections.  

Multiple vaginal exams throughout the labor process put you at an increased risk of developing an infection. Increased risk does not mean an inevitable experience. It simply means that your risk is higher compared to someone who is not being induced. 

Cesarean Delivery. It is controversial whether you are at an increased risk for having a C-section if you choose to be induced at 39 weeks. Until very recently, most sources advised against the induction of labor before 41 weeks, which is one week after your due date. Especially if your cervix is closed, and, this is your first time having a baby. However, more recent studies show that your C-section risk may be lower with an induction at 39 weeks versus 40-41 weeks if your pregnancy is low-risk. 

What Methods are Used for Labor Induction?

• Membrane Stripping 
• Nipple Stimulation 
• Cervical Ripening Agents 
• Medication
  • prostaglandins (cervidil, misoprostol, prepidil) 

• Non-Medication
  • Dilapan S and foley balloon (both are devices placed in the cervix to help it dilate).

• Oxytocin 
• Amniotomy- your doctor breaks your water bag 

How Will my Doctor Decide Which Medicines or Methods to Use for My Induction? 

Your obstetrician may tell you that your cervix is “unripe” or “unfavorable” after your cervical check. While these terms sound terrible, don’t take offense. These are simply medical terms that indicate your cervix isn’t ready for hard contractions. Ideally, your body will respond best to stronger contractions when your cervix has started to open (or dilate) and is at least halfway thinned out (50% effaced). You may need to have your cervix ripened to increase your chance of a successful induction. Several techniques can be used to ripen the cervix.  

Membrane Stripping is a procedure performed in your doctor’s office. During a vaginal exam, your doctor sweeps her fingers between your cervix and your amniotic sac. Amniotic sac is the medical term used to describe the bag of water that surrounds the baby. Stripping your membrane releases hormones that stimulate mild contractions. Hospitalization is not required. You simply go home. 

Nipple Stimulation is rarely used in modern medicine. Nipple stimulation involves either a self-stimulation of your nipples or the use of a breast pump. The stimulation of your nipples creates a release of a hormone called oxytocin. Oxytocin is released in the brain and causes mild uterine contractions. This method does not require hospitalization.

Cervical Ripening Medicines

Prostaglandins are a group of hormones that works on your cervix. The cervix is the opening or mouth of your womb. As the uterus contracts, the cervix needs to open up to allow vaginal delivery. If your cervix has not yet opened sufficiently or at all, you will need some help to allow this to happen so you can have a successful labor induction. This can be done through the use of prostaglandin medicines or a balloon-shaped device called transcervical foley.   

Dinoprostone: works similarly to misoprostol but is available in a vaginal gel form (brand name Prepidil) or a removable vaginal insert (brand name Cervidil). Both of these medications are placed in the vagina, behind the cervix. A potential advantage to cervidil is that it can be removed if contractions become too frequent. However, dinoprostone gel and inserts are expensive compared to misoprostol. Unfortunately, many insurance companies and hospitals are no longer providing these medication options. This means that your obstetrician or midwife may be limited in what they can offer you during your induction. There are some women that should not use prostaglandins in labor. If you had a previous cesarean section or certain uterine surgery, the use of prostaglandin in labor has a higher risk.

Cervidil is a prostaglandin medication. The medicine is in a small flat device wrapped in nylon with a string attached. It releases medicine for up to 12 hours. Your doctor may allow it to stay in for the full 12 hours or have it removed sooner. It helps to soften and thin out your cervix. You may feel some contractions, but the pain is usually mild. One advantage of cervidil is the fact that the medicine can be easily removed if needed. Cervidil may need to be removed if your contractions are too strong for your baby to handle. You may or may not desire medication for pain relief during this time. It is rare to need an epidural at this stage of your induction. Cervidil is usually inserted at night, in the hospital, at the start of your induction. Expect to rest and relax. 

Prepidil is also a prostaglandin medication similar to cervidil, but is in a gel form and requires more frequent dosing. The gel is inserted into the vagina with use of a syringe. Once inserted, prepidil cannot be removed. Due to the need for frequent dosing, this medication has fallen out of favor. Prepidil is rarely used and has mostly been replaced by cervidil.  

Misoprostol (brand name Cytotec):is also a prostaglandin medication. It is a tiny pill that can be given by mouth or placed vaginally to soften the cervix. Once cytotec is given, it cannot be removed. It is effective and safe if used correctly. Sometimes, if you are contracting more frequently than every 3 minutes, this medication will not be used. The medicine is given every 4 to 6 hours until labor starts, or the cervix dilates.   Because cytotec is a more potent drug, you will experience stronger contractions, but your labor will be shortened compared to cervidil.

Transcervical Foley Balloon Transcervical foley is a special catheter with a balloon at the tip to help dilate the cervix. This balloon is inserted during a vaginal exam. The catheter is passed through the vagina, through the cervix, and into the uterus. Once the balloon tip is just beyond the cervix, and inside the uterus, the balloon is filled with sterile fluid. This anchors the balloon, which presses its weight against your cervix. The catheter of the balloon is then taped to your leg. This allows the balloon to place pressure on your cervix and encourage faster dilation. Additional medications may also be given so that the two methods are working together to encourage faster ripening. Another option is to have the catheter placed in the clinic or hospital triage area. You then go home for the night and come back in the morning, or sooner if your labor starts before then. This allows for one more night of rest in your own home and is a good option if your pregnancy is considered low-risk. 

Dilapan-S Dilapan-S are FDA approved, non-pharmacological cervical dilators.These are rods, that do not contain any medicine. With the use of a speculum and a few other devices your physician or midwife will place the rods into the cervix. Anywhere from 1 to 3 rods may be inserted, though more typically 3-5 are used. As the rods absorb fluid they grow in size, place pressure and dilate your cervix. Once inserted, the rods should be removed no later than 24 hours later. Though most women will achieve results within 12-15 hours. Your physician will remove the rods. You and your doctor will decide if you will go home or stay in the hospital with the rods in place. Dilapan-S has the advantage of being fully inside your body with no portions extending outside the vagina, which may improve comfortability.v

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So My Cervix is Now Ripened… What’s Next? 

Some women will go into labor during the cervical ripening process (Yay!), but not all. Most times, there’s still work left to do. After your cervix is ripened, you will likely have your water bag broken (amniotomy) and be started on a medicine called oxytocin (pitocin). At this point, your cervix should be at least 2 to 4 centimeters dilated and 50% thinned out or effaced. If this is not the case, you may need a repeat of the same or a new cervical ripening method. Once your cervix is ripened, the goal becomes to get you into what is called active labor. Getting you into active labor will involve your doctor breaking your water; if this has not yet occurred. Another medication called oxytocin (Pitocin) is also used. 

Amniotomy is a fancy word for breaking your water. This is a quick and painless procedure. During a vaginal exam, your doctor uses a blunt, plastic hook device that looks similar to a large crochet needle. The hook is used to snag the amniotic bag and release the fluid. A large pool of amniotic fluid will flow from your vagina. This is normal. The fluid will continue to flow throughout labor, as your body continues to produce amniotic fluid even after the bag is broken. Amniotomy causes the release of your body’s own naturally producing prostaglandins. This makes your uterus more sensitive to the contractions and speeds up labor. Once the amniotic sac is released, your baby’s head presses down on your cervix, causing further dilation. Your doctor will decide when is the appropriate time for your water to be broken. The baby should be low enough in your pelvis to prevent a complication from occurring with your umbilical cord (umbilical cord prolapse). Sometimes, amniotomy isn’t needed because the labor progresses fine without it, or the water breaks on its own. 

Oxytocin (Pitocin) is a neurotransmitter hormone made in the brain that has a few different functions in the body. It is known to be important in social bonding. It also controls milk let-down during breastfeeding; however, the function that we are interested in here is its most common use in medicine: to cause strong and frequent uterine contractions. It is often used in labor inductions with great success.

Oxytocin is given intravenously (IV), but you may still be able to move around freely, change positions, sit in a chair or on a birthing ball. You will be able to walk with your IV pole.  Oxytocin is started with a tiny dose and increased slowly. This allows your baby to adjust to the uterine contractions at a measured pace. It can be stopped if the contractions become too frequent or intense. Fast administration of oxytocin can cause your contractions to occur too fast and too strong. Your baby may not be able to tolerate this and show signs of fetal distress. Your baby’s heart rate and your uterine contractions are monitored very closely at this stage of your labor induction process.

In some cases, oxytocin may be used at a low, constant dose as a cervical ripening agent, either alone or in combination with a balloon catheter.

Labor Augmentation

Lastly, there is a common scenario that sometimes occurs. Your body starts to labor, you contract regularly, your cervix dilates but then the process stalls. This can be quite painful. You continue to feel pain and discomfort, but your cervix just isn’t dilating. This is called prolonged or protracted latent labor. If this occurs at 39 weeks gestation or greater, your doctor may offer you medicines to nudge your labor along. Because you have already started laboring, we refer to this process as an augmentation of labor, not an induction.

Augmentation may also be offered if your water breaks, but you fail to have contractions. In this scenario, augmentations may be started right away or up to 24 hours after breaking your water. Waiting beyond 24 hours places you at an increased risk for infection and cesarean section.

As you progress to six cm dilation, your labor should move along at a faster pace. But remember, while this is true for many, it does not apply to all. Try to keep an open mind in labor. Stay relaxed as much as you can. If your labor stalls, your practitioner will have a few tricks up her sleeve – she’ll want to smooth the way for you as much as possible until she walks in the room to hear you announce breathlessly, “I think it’s time!”

Written by: Kristen McBride MD, March 09, 2020 | Editor: Dayna Smith, MD | Reviewed October 1, 2020 | Copyright: myObMD Media, LLC, 2020 

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Glossary: 

Intrauterine Growth Retardation (IUGR)– a fetus with IUGR shows growth that is abnormally small. A fetus with IUGR shows a growth pattern at the tenth percentile or lower. That means ninety percent of fetuses, that same age, are larger.  

Breech Presentation– a fetus whose head is not the body part closest to the vagina. The fetal part closest to the vagina may be the feet. 

Preterm Premature Rupture of Membranes (PPROM)– when your water breaks in a preterm pregnancy. 

Active Labor– stage of labor when your rate of dilation is fast and predictable. Usually active labor starts when you are 4-6 cm dilated. 

Umbilical Cord Prolapse– when the umbilical cord delivers before the baby is out. This is a surgical emergency that requires emergency C-section. 

Aspiration-when the stomach contents is regurgitated up into the esophagus and then goes down into the lung. This can cause severe lung damage. 

Neonatal Intensive Care Unit– ICU for babies.